Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-3011
2. Registrant Information.
Registrant Reference Number: 474956
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: Suite 100, 3131 114 Avenue SE
City: Calgary
Prov / State: AB
Country: Canada
Postal Code: T2Z 3X2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
20-MAY-09
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
Unknown
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 72155-44
Product Name: Season-Long Grub Control Granules with Fertilizer (non-specific)
- Active Ingredient(s)
- IMIDACLOPRID
- Guarantee/concentration .2 %
7. b) Type of formulation.
Granular
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Great Dane
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1.5
7. Weight (provide a range if necessary )
118
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Death
- Symptom - Dehydration
- Symptom - Adipsia
- Symptom - Lethargy
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
5/20/2009 Caller reports applying the product repeatedly around his home for the last two to three years. The caller's dog recently developed anorexia, lethargy, and adipsia. The dog was taken to the veterinarian for evaluation. The veterinarian took radiographs and performed an exploratory surgery, but was unable to determine the cause of the dog's symptoms. The caller states that the DVM did note the bowels were bruised, the lymph nodes were enlarged, and the liver enzymes were elevated on the lab work. The dog was dehydrated and was placed on intravenous fluids. The dog died the following day at the clinic. The dog had no witnessed exposure to the product. The possibility of pesticide exposure is speculative.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here